Eric Van Dooren | Florin Cofar

Victor Clavijo | Gustavo Giordani | Venceslav Stankov

Interdisciplinary Esthetic Dentistry

– basics
Planning
The and execution
big
Picture Volume 1
Foreword

First and foremost, this book is written by clinicians for clinicians.

It always aims for a pragmatic approach to solving problems
in the clinical reality. By mixing timeless concepts with ever-evolving
technology, it takes the reader on a journey, providing both the context
and the solutions to problems we face every day.

The clinical work in this book has been executed on a time frame
of 30 years, across 3 different geographic and cultural realities
(Western Europe, Eastern Europe and Brazil), yet sharing a common
and congruent vision on how to approach dentistry.

This book is a compendium of core interdisciplinary concepts

and ever-evolving tools and workflows to handle complex scenarios.
Last but not least, it is a tribute to the people we worked with,
and probably most important, it is a tribute to the people we served.

We wish you happy reading.

Eric Van Dooren and Florin Cofar

V
 Eric Van Dooren, DDS
Dr Van Dooren attended the Katholieke University
in Leuven, Belgium, where he received his degree
in dentistry in 1982.
After graduation, he opened a private practice
in periodontics, fixed prosthodontics, and implants
in Antwerp, Belgium.
He is an active member of the European Academy
of Esthetic Dentistry.
Dr Van Dooren lectures nationally and internationally
mainly on esthetics, implants, and esthetic
periodontal surgery.
VI
Florin Cofar, DDS
Dr Cofar graduated University Victor Babes,
Timisoara, Romania, in 2007.
He is specialised in interdisciplinary esthetic dentistry,
with a broad expertise on digital technology.
As a philosophy, he is geared towards clinical
pragmatism, efficient and meaningful use of technology
to broaden the holistic diagnosis and treatment
capabilities in oral rehabilitations.
Currently lectures worldwide and practices
in Timisoara, Romania.
Victor Clavijo, DDS
Dr Clavijo holds a degree in Dentistry from Universidade
Paulista, São Paulo, Brazil (2002) and obtained
the title of Specialist, Master and Doctor in Restorative
Dentistry, from UNESP Araraquara (2003–2011).
Despite his academic background, his focus is
on clinical care. He has followed in the footsteps
of his father, who has been a clinician for over 50 years
in the city of Indaiatuba, São Paulo, Brazil.
He has more than 60 articles published in national
and international journals and has authored
and co-authored books in the dental field.
His work is based on clinical and scientific evidence.
Currently, he divides his time between appointments
at his clinic, classes, and courses in Brazil and abroad.
In addition, he contributes to research in dentistry;
he conducts research annually at the University
of Southern California, Los Angeles, USA,
as a visiting professor.
Gustavo Giordani, DDS
Dr Giordani has specialized in maxillofacial and periodontal
surgery, and implantology. After graduating from
the Universidade Paulista (UNIP), São Paulo, Brazil,
he took a fellowship in Belgium, on “Implants
and Periodontal Plastic Surgery” with Dr Eric Van Dooren,
collaborating with him to the present day. Dr Giordani
is treating cases in an interdisciplinary fashion,
working with specialists all over the world.
He lectures internationally on soft tissue management,
periodontology, and implantology in prosthetic treatments.
His main focus is treatment for gummy smile,
esthetic crown lengthening, root coverage, gingival grafts,
and immediate implants. He works closely with the Dentcof
team and Ateliê Oral, one of the most successful dental
clinics in São Paolo.
Venceslav Stankov, DDS
Dr Stankov is among the best-positioned professionals
in the domain of dental medicine in Bulgaria. He manages
a team of 24 staff as the Chief Doctor at the Dr Stankov
Dental Clinique. His clinical work is focused on end-to-end
esthetic treatment in dental medicine, implantology,
periodontal plastic microsurgery, periodontal regeneration,
complex cases of prosthetics on natural teeth, and implants.
He is a renowned and influential national lecturer
and a trendsetter in his area of expertise.
He has taught several postgraduate courses in the fields
of periodontology and prosthetics. He won second prize
in the 1-year Global Institute for Dental Education (GIDE) master
program at the University of California, Los Angeles, USA, in 2013.
His career started after he graduated in dental medicine
at the Faculty of Dental Medicine, Medical University of Plovdiv,
Bulgaria, in 2007. He is a visiting lecturer at the Zimmer Institute,
Switzerland. He is an active member of the Bulgarian Academy VII
of Esthetic Dentistry, the GIDE Study Club, and the Zimmer Club.
 Contributors
Special mentions Orthodontics Laboratory Planning
Edward Pat Allen Marcelo Giordani Adina Barbur Leonardo Bocabella Andrei ‘Fred’ Bazavan
Ioan Cofar Galip Gürel Ioan ‘Johnny’ Barbur Murilo Calgaro Emil Bobev
Karim Dada Paulo Kano Nuno Sousa Dias Willy Clavijo Lenu Boca
Léon Pariente Stefen Koubi Christian Coachman Lucian Ciu
Adrian ‘Ginger’ Argint Dan Lazar Wagner Nhoncance Gabriela Lascu
Nitzan Bichacho David Norre Ioana Popp Adrian Roman
Benjamin Cortasse Alexander Schryvers Christiano Soares
Mauro Fradeani

VIII
Visuals Logistics Assistants Co-contributors
Ciprian Boca Andreea Buciuman Loredana Chitimia Adrian Badarau
Marcel Carson Madalina Duma Cristina Hajnal Hornea Florin Bratiloveanu
Flavius Neamciuc Oana Herta Camelia Miu Alin Dinca
Mihai Simona Maria Macarescu Roxana Patrut Vinicius Machado
Karolina Veruzab Jordi Manauta
Thiago Ottoboni
Anna Salat
Cristina Sas

IX
 Interactive videos
Augmented reality in this book! The

This book contains augmented reality videos available free

big
Picture
Download
the app “Quintessence Van Dooren-Cofar”
from the Apple Store (iOS) or Google Play (Android).
of charge from your smartphone or tablet.

Easy to use, reliable, instantly accessible, and available

offline, you can find selected multimedia content created Select a chapter
by the authors to enrich your reading experience. 1 among those with augmented
reality content.

Locate
clinical photographs
with the augmented reality symbol.

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 Roll over
these photos on your smartphone
or tablet using the app to play the videos.

X
XI
 – basics Planning and execution – Volume 1

Contents
Foreword ............................................ V

Contributors ...................................... VIII

Esthetic analysis
1
Conventional smile design ..................... 1
Prosthetically guided healing
Simultaneous white
2
and pink reshaping .................................... 81

Interactive videos ................................. X

Suggested reading ................... Volume 3

Esthetic analysis
3
The digital paradigm shift .................. 129
4
Boosting the biotype ................................ 175

Nonsurgical soft tissue management

Reshaping 3D root configuration.... 271
5 Working with dark substrates
Surgical and prosthetic
6
considerations .......................................... 359

Interactive videos
This book contains
augmented reality
videos available for free
from your smartphone or tablet.
7
Crown lengthening ................................... 427
Sequencing gingival
8
recession covering .................................... 531
– synergies Optimising complex cases – Volume 2

9
Orthodontics considerations

– complications Retreatments and maintenance – Volume 3

10 11 12 13
The central-lateral
Delaying implant incisor dilemma Full arch Retreatment 1

14 15 16 17 18 Vertical maxillary Vertical maxillary

Connective tissue growth growth The pink gingival
Retreatment 2 hyperplasia in young adults and implant removal restoration
Esthetic analysis
1
Conventional smile design

1
2
 1
Introduction

A
successful outcome depends on a well-organized and step-by-step approach,
a meticulous treatment planning protocol, and basic knowledge of prosthetic
and surgical concepts. The entire treatment sequence for the patient can be divided
into four equally important steps:

≥ The first step is about clinical examination, periodontal assessment, collection of the data
needed to treat the case, and esthetic analysis to establish a proper diagnosis and to transmit
the correct information to the laboratory; receiving accurate information from the clinician
is important so that the occlusal plane is not skewed, the midline is not canted,
and functional problems are not incorporated into the diagnostic wax-up
that will be used to build the esthetic project.

≥ The second step is to build the ideal design for the patient and validate it
with a mock-up to get the patient to approve treatment.

≥ The third step includes all the sequences of treatment needed to reach this goal.
≥ The fourth step is the final prosthetic rehabilitation.
3

A final step should be added to all treatment plans, that is, maintenance and hygiene; the last part of this
book is all about the long-term challenge we face with our rehabilitations and focuses on these issues.
4
 1
Clinical situation

A
42-year-old woman was referred to our clinic by an orthodontist.
Her main complaints were the unesthetic appearance of her smile,
particularly the anterior segments, and sensitivity in her left central incisor.
Her goals in seeking treatment were to improve the esthetics and create
balance and harmony in her smile.

Because she had been complaining about sensitivity in her left central incisor,
she was referred to an endodontist for evaluation before any further treatment.
The endodontist confirmed a root fracture in the left central incisor; that tooth
should be planned for extraction and implant placement.

5
6
Step one
1
Observe
Backgrounds Face
≥ 42-year-old woman ≥ Harmony: substantial canting of the maxilla
≥ Referred by her orthodontist ≥ Symmetry: deviation of the midline
≥ Left central incisor planned for extraction ≥ Substantial canting of the anterior segment

Complaint Smile
≥ Improve the esthetics ≥ Slight gummy smile
≥ Create balance and harmony in her smile ≥ Asymmetry in the form of the central incisors
≥ Old discolored composite material

“ The observation always starts with the patient’s

face, then little by little we focus on smaller
and smaller details. Relating the smile and the tooth
7
display to the face of the patient is crucial
for a proper smile design.
”
 Step one

Record
Key elements for the development of the esthetic and functional treatment plan

Extraoral frontal view perfectly centered to avoid any distortion; extraoral lateral views

8
Extraoral close up of the smile
1. Extraoral photographs 1

“ At this step, video recording can be useful to have

a full understanding of the lip dynamics of the patient.
”
10

“ It is essential to think like an architect

before you act like a dentist.
”
 1
Step one
Record
Key elements for the development of the esthetic
and functional treatment plan

2. Intraoral photographs
≥ Frontal view perfectly centered to avoid any distortion

≥ Lateral views

≥ 12 o’clock picture

3. Intraoral radiographs
≥ Apical radiolucency around the roots of the left central and lateral incisors

11
 4. Impression

12 “ Special attention must be

paid to the impressions needed to obtain
the study casts to ensure that the information
is transmitted faithfully to the laboratory.
”
5. Facial references 1

“ The easiest way to transfer this canting of the midline

to the laboratory is to draw two lines on the intraoral
photograph. First, a horizontal line should be drawn parallel
to the pupillary line. Second, a midline should be drawn,
13
preferably perpendicular to the horizontal line.
The two same lines are then drawn on the study cast.
”
14
270
management
Reshaping 3D
5
Nonsurgical soft tissue

root configuration
271
272
 5
Introduction

H
istorically, implant restorations were the first to benefit from the design-induced
healing. Indeed, implants are always surmounted by prosthetic parts that allow to
model the peri-implant mucosa. These parts were initially premanufactured,
resulting in standardized healing; with the introduction of cervical contouring
by Bichacho, we began to produce individualized parts based on a working model
with the desired modifications and were thus able to model and measure the peri-implant tissues.
These modifications were in most cases purely subtractive at the tissue level, but we began to
understand the effect of subtractive techniques at the level of the designs themselves
and understood that we could work with the tissue in both directions: a subtractive technique
at the level of the prosthetic element allows us to obtain a gain of gingival volume and a
displacement of tissues in the coronal direction, whereas an additive technique at the level of the
prosthetic element (identical to the subtractive technique carried out on the model during cervical
contouring) causes a decrease of gingival volume and tissue displacement in an apical direction.
The two clinical cases described in this chapter perfectly illustrate this treatment approach.

273
274
 5
Clinical situation 1
T
his 27-year-old patient was referred to us for replacement of her right maxillary
incisor. She is particularly concerned about the mobility of her right incisor.
She would also like to improve the esthetic aspect of her incisor
but her first motivation is clearly not to remain without teeth.
Her practitioner has already discussed the implant with her
and she would like to avoid a transitional removable prosthesis as much as possible.

275
276
“ The observation always starts with the patient’s face,
then little by little we focus on smaller and smaller details.
Relating the smile and the tooth display to the face
of the patient is crucial for a proper smile design.
”
Step one
5
Observe
Backgrounds Face
≥ 27-year-old woman ≥ Harmony: substantial canting of the maxilla
≥ Referred by her orthodontist ≥ Symmetry: deviation of the midline
≥ Left central incisor planned for extraction ≥ Skin

Smile
Complaint ≥ Forced smile, physiologic rest
≥ Improve the esthetics ≥ Lips
≥ Create balance and harmony in her smile ≥ Teeth: discrepancies in shape
and size of the incisors

277
278

Altering the gingival profile and contour

Step two
Altering the gingival profile
and contour
On closer examination, we can see that the
patient has a recession on the right maxillary
lateral incisor, the necks of the two central
incisors have shifted, and we can note
a deficit of vestibular tissue on the right
maxillary central incisor, as well as
a thickness defect on its distal papilla.
Starting treatment with these parameters,
it is risky to fix a defect at the time of
extraction and it is also risky not to locate the
5
implant platform at the right level
in the vertical plane. It is therefore essential
in this type of situation to start correcting
the periodontal environment even before
extraction by reworking the dental substrate.
This is an extremely simple procedure
from a technical point of view and this 3D
reconfiguration of the emergence of the tooth
will allow an extremely important simplification
of the situation.

“ Visualizing the final design before performing any surgical

or prosthetic procedure is key to success and will allow
formulation of the right treatment plan for your patient.
”
279
 “ Altering the gingival profile and contour
is an extremely simple clinical procedure that
in some situations leads to a radical change
in the clinical situation. Here, we can observe
that the two necks of the maxillary central
incisors are aligned and that the vestibular
tissue deficit has also decreases;
only the thickness defect at the distal
papillary level remains.
”

280
5

281
 Input Design

282

Output

Step two
Initial design
One of the major benefits of digital dentistry is
the introduction of copy and paste dentistry.
In situations where the goal is to integrate in
the finest way with the existing environment,
the ideal shape is at hand and is now extremely
easy to reproduce. In this case, it is the shape
of the left maxillary central incisor that can
be easily selected and adapted to the site of
the right maxillary central incisor. Quickly and
efficiently, the laboratory technician can obtain
5
the ideal design for this tooth to be replaced,
with the guarantee that it will easily fit into
its new environment. The study of this design
also determines the amount of tissue still
missing around the tooth and will guide the
connective tissue graft that will heal itself
according to the established design.
Once finalized, this ideal design can be printed
and a silicone key will provide the ideal
mock-up.
283
 Initial preparation and removal of composite

Ideal 3D position of periodontic–prosthodontic interface

284

Step two
Mock-up
At this stage, the composite is deposited
and the tooth is roughly prepared with the sole
objective of providing sufficient space
for the mock-up. The mock-up is made using
the silicone key created on the printed model,
and good integration of the final design
is validated.
5
A Duralay resin index is made, which allows
the prosthetic tooth to be repositioned in an
exact 3D position during the extraction and
implantation procedure. Another way to do
this would have been to have a provisional
made with distal and mesial fins for
temporization at the implant stage.

“ Visualizing the final design before performing

any surgical or prosthetic act is key to success
and will allow you to right treatment plan for your patient.
”

285
 Tips and tricks

286
 5

“ The key made of Duralay resin allows us

to keep all the information of the 3D position
of the temporary tooth; thus, all the benefits 287

of the ideal design will be transferred to

the temporary tooth on the implant.
”